Patient's Name* DOB* 1. Was this your first visit to our office? Yes No2. Reason for your visit? 3. Convenience of setting your appointment Extremely convenient Moderately convenient Slightly convenient Not at all convenient I did not have an appointment4. Did the receptionist introduce himself/herself and greet you in a friendly and courteous manner? Yes No5. Cleanliness/neatness of the waiting room Average Outstanding Poor6. How long did you have to wait to be seen after checking in with the receptionist? 5-10 minutes 11-20 minutes 21-30 minutes over 30 minutes Other (please specify) Comments:7. How friendly was office staff? Extremely friendly Moderately friendly Slightly friendly Not at all friendly8. Was the physician able to put you at ease? Yes No Comments:9. How well did you feel that we understood your needs? Extremely well Moderately well Slightly well Not at all well Comments:10. Quality of the service Outstanding Above Average Average Below Average Poor Comments:11. How responsive was the staff to your questions or concerns? Extremely responsive Quite responsive Moderately responsive Slightly responsive Not at all responsive12. The ease of checking out and paying Extremely convenient Moderately convenient Slightly convenient Not at all convenient13. Rate your experience with referrals to specialists (our office's ability to keep you informed and up-to-date on the status of your request) Outstanding Average Poor14.How likely is it that you would recommend Bristol Primary Care LLC to your friends or family? Not at all likely - 0 1 2 3 4 5 6 7 8 9 Extremely likely - 10"15. In your own words, let us know any positive experiences you had or issues or concerns you may have about our services or office practices and procedures.16. Would you like to be contacted regarding this survey? Yes No Please note that any information submitted using this form is transmitted securely and held in the strictest confidence, ensuring the protection of your privacy Δ